Functional Therapies
Intake Form
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Senegal
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Suriname
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Taiwan, Province Of China
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Tanzania, United Republic Of
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Venezuela, Bolivarian Republic Of
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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
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Additional Info
Conditions
Well Being
Interests
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Mobility/Walking Aids
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Drinking
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Smoking
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Exercise
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Caffeine
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Sports
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Flexibility
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Range of Motion
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Hobbies
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Treatment Goals
Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Other
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Energy
When is your energy highest?
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When is your energy lowest?
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What is your energy level upon awakening?
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How long do you sleep on average?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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Is your energy constant?
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TMJ (Jaw)
Ear Ringing
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Ear Stuffiness
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Jaw Pain
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Ear Pressure
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Clicking
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Ear Blockage
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Locking
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Difficulty Opening Jaw
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Difficulty Chewing
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Grinding
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Clenching
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Morning Stiffness
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Feet
Onychoptosis (Nail Loss)
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Bunions
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Corns/Callouses
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Onychomycosis (Nail Fungus)
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Itchy or Peeling Skin
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Involuted Nails (Curved/Pinched)
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Dry/Cracked Skin
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Thickened Nails
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Heel Fissures
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Yellow Nails
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Previous Amputations
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Onychocryptosis (Ingrown Nail)
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Onychauxis
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Pes Planus (Flat Feet)
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Pes Cavus (High Arch)
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LIV/GB (Wood)
Headaches/Migraines
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Shingles
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Teeth Clenching at Night
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Emotion / Memory
Alzheimer Disease
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Anxiety Disorder
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Mood Disorder
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Schizophrenia
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Stress
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Substance Use Disorder
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Health Questions
Pacemaker
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Warts
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Infectious
Lyme Disease
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KID/UB (Water)
Weakness/Pain in Lower Back
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Agree to wear face mask during treatment
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Have you tested positive for COVID-19?
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Have you been tested for COVID?
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Shortness of Breath
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Difficulty Breathing
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Contact with someone who is awaiting COVID test results.
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Contact with someone who was in contact with COVID
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Within the last 14 days, have you tested positive for COVID-19 or experienced any COVID-19 symptoms?
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Have you travelled abroad in the last 14 days?
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Have you received a covid alert that you were in close contact with someone with covid, through the covid app in the last 14 days?
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Been in group where social distancing not observed
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Spend time around anyone that is high risk
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No COVID Symptoms
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Female Health
Implants
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Pelvic Floor Injury
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Scar Tissue
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Pelvic Pain
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Pain with Sex
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Cluster
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Rebound
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Other Headaches
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Reproductive
Menopause
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Pelvic Inflammatory Disease
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Pregnancy
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Endometriosis
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Skin
Athlete's Foot
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Chemical Burn
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UV Burn
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Hypersensitive Reaction
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Hypersensitive Reactions
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Eczema
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Herpes
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Melanoma/Carcinoma
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Bruise Easily
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Pigmentary Disorder
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Non-Surgical Scars
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Melanoma
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Plantar's Wart
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Surgical Scars
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Acne
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Psoriasis
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Allergic Dermatosis
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Rash
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Skin Conditions
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Infectious Skin Conditions
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Athletes Foot
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Rosacea
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Skin Irritations
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Blood
Hepatitis
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Hypercoagulability
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Haemophilia
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HIV
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Polycythemia
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High Cholesterol
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Thrombosis/Embolism
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Anemia
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Bleeding Disorder
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HIV/AIDS
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Musculoskeletal
Baker's Cyst
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Compartment Syndrome
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Joint Stiffness / Swelling
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Psoriatic Arthritis
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Ehlers-Danlos Syndrome
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Whiplash
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Recti Diastasis
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Dislocation
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Spasms / Cramps
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Scleroderma
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Tendonitis/Bursitis
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Osteoporosis
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Fracture
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Spondylolisthesis
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Osteoarthritis
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Scoliosis
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Temporomandibular Joint Dysfunction
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Hereditary/Congenital Deformity
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Sinus Problems
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Strain/Sprain
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Gout
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Carpal Tunnel Syndrome
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Artificial Joints / Special Equipment
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Adhesive Capsulitis
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Bone or Joint Disease
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Plantar Fasciitis
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Osgood-Schlatter Disease
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Muscular Dystrophy
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Degenerative Disk Disease
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Ankylosing Spondylitis
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Broken Bone / Fracture
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Osteomalacia
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Fibromyalgia
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Chronic Myofascial Pain Syndrome
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Myasthenia Gravis
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Arthritis
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Jaw Pain (TMJD)
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Torticollis
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Bone Disease
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Dupuytren's Contracture
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Paget Disease
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Chronic Fatigue Syndrome
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Other Musculoskeletal
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Neurological
Cerebral-vascular Accident
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Multiple Sclerosis
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Tingling
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Huntington Disease
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Stabbing
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Loss of Sensation
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Brain Disorder
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Stroke
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Chronic Pain Disorder
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Carpal Tunnel
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Brain Injury
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Fibromyalgia
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Epilepsy
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Cerebral Vascular Accident (Stroke)
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Cerebral Palsy
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Peripheral Neuropathy
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Seizure Disorder
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Shingles
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Parkinsons
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Numbness
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Transient Ischemic Attacks (TIA)
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Dizziness
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Herniated Disc
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Burning
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Vertebral and Spinal Cord Injury
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Sciatic Pain
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Respiratory
Chronic Cough
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Respiratory Conditions
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Tuberculosis
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Shortness of Breath
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Respiratory Tract Infection
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Asthma
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COPD
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Emphysema
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Cystic Fibrosis
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Bronchitis
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Infectious Respiratory Conditions
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Immune
Hodgkin Lymphoma
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Infectious Mononucleosis
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Leukemia
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Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Allergies
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Anaphylaxis
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Lupus
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Cancer
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Endocrine
Acute Pancreatitis
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Hyperthyroidism
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Hypothyroidism
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Diabetes
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Pituitary and Growth Disorder
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Prostate Condition
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Cardiovascular
Heart Attack
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Cardiac Arrhythmia
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Rheumatic Heart Disease
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Blood Clots
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Phlebitis
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Chronic Ischemic Heart Disease
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Valve Disorders
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Lymphedema
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Chronic Venous Insufficiency
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Cardiovascular Accident
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Congenital Heart Defect
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Acute Coronary Syndrome
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Cold Hands
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Pacemaker
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Coronary Artery Disease
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High Blood Pressure
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Aneurysm
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Cold Feet
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Heart Disease
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Hyperlipidemia
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Myocardial infarction
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Low Blood Pressure
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Angina
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Blood Pressure
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Pericarditis
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Varicose Veins
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Congestive Heart Failure
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Atherosclerosis
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Cardiovascular Conditions
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Raynaud Disease
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Gastrointestinal
Eating Disorder
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Crohn's Disease
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Esophageal Disorder
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Irritable Bowel Syndrome
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Poor Appetite
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Celiac Disease
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Stomach Disorder
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Constipation
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Ulcerative Colitis
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Diarrhea
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Diverticulitis
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Digestive Conditions
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Ear Problems
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Motion Sickness
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Hearing Loss
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Tinnitus
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Vertigo
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Miscellaneous
Vision Problems
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Vision Loss
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Mental Health Issues
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Surgical Pins or Wire
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Insomnia
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Loss of Balance
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Other Medical Conditions
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Other Diagnosed Diseases
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Massage Goals
Improve Fitness
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Pain Relief
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Increase Well-Being
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Injury Rehabilitation
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Positive Reinforcement
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Strength Training
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Address Health Issues
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Stress Relief
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Alternative Therapy
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Balance
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Improve Symptoms
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Flexibility
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Massage Frequency
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Other
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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0
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Staying the Same
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0
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Tension
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0
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Disabling
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0
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Getting Better
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0
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Discomfort
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0
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Constant
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0
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Imbalance
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0
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Intermittent
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0
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Increases with Activity
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0
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Decreases with Activity
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No Change
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0
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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0
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Other creams, gels or unguents
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0
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Other therapies
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0
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